Monday, June 29, 2009

Comment writer asks retired doc about single payer

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.

3 comments:

Anonymous
said...

Normally I find your posts very interesting and insightful, but when it comes to discussion of reform of the health care system, I can't really agree with your perspective. Your post suggests that the major issue is whether the govt will allow private competition to a new single payer system (the creation of which, in your view, seems to be a foregone conclusion). But the debate I am reading about in the papers and on the Web is about whether there will be any public option at all. Your suggestion that we might end up with a system like Canada's seems like a hyperbolic strawman argument designed to frighten more than enlighten. Private insurance is not going away, and your suggestion that it might seems like a scare tactic.

Nice article, I wonder if this situation in the US could be solved with a simple test. We see how all the single payer systems work around the world but it's different in every country. Mr. Obama should have one county in the US adopt the single payer system for a period of time and see how it runs, see the peoples responses, get a lot of stats and graphs with interesting numbers and then show it to the people. And then decide on that. It would be a lot of work but maybe it would satisfy all the people.

I've been following all these arguments with interest, trying to discern the motivation behind the "conservative" rhetoric that has sprung up behind the latest health reform debate. I'm trying to stifle my cynicism that tells me this is just self-interest on the part of some in the medical community who want to maintain their prerogatives that they worked so hard for, and by insurance company executives who have established for themselves and their posterity for a dozen generations a privileged place in American society. The whole motivation for this latest round of healthcare industry reform has been the demand by the people to, once and for all, put an end to the egregious misbehavior on the part of the private health insurance (a malapropism if there ever was one) industry, and their shills, that is bleeding us dry and leaving us sick and dying. The best "assisted suicide" I can imagine is getting a policy with Aetna and "forgetting" to tell them that I had a squamous cell carcinoma resected when I was a teenager.